腹腔镜肝切除术治疗肝内胆管癌的临床疗效

Clinical efficacy of laparoscopic hepatectomy for intrahepatic cholangiocarcinoma

目的探讨腹腔镜肝切除术治疗肝内胆管癌的临床疗效。方法采用回顾性横断面研究方法。收集2013年1月至2018年1月福建医科大学孟超肝胆医院(32例)及陆军军医大学第一附属医院(30例)收治的62例肝内胆管癌患者的临床病理资料;男35例,女27例;平均年龄为60岁,年龄范围为25~77岁。根据术前及术中探查情况选择行淋巴结清扫术,再根据肿瘤大小及位置选择行腹腔镜解剖性或非解剖性肝切除术。观察指标:(1)手术及术后恢复情况。(2)病理学检查结果。(3)随访及生存情况。采用门诊和电话方式进行术后随访,每3个月随访1次,了解患者无瘤生存和总体生存情况。随访时间截至2018年6月。正态分布的计量资料以Mean±SD表示,偏态分布的计量资料以M(范围)表示,计数资料以绝对数或百分比表示。采用Kaplan-Meier法绘制生存曲线并计算生存率。结果(1)手术及术后恢复情况:62例患者均成功行腹腔镜肝肿瘤切除术,无中转开腹,无围术期死亡。62例患者中,40例行解剖性肝切除术、22例行非解剖肝切除术;18例患者同时行区域淋巴结清扫。62例患者手术时间为(217±86)min;12例患者术中行Pringle法入肝血流阻断,总阻断时间为(14±7)min,45例患者行选择性入肝血流阻断,5例患者未行肝门阻断;术中出血量为282mL(20~2500mL),4例患者术中输注悬浮红细胞;术后下床活动时间为1d(1~3d),术后首次肛门排气时间为2.5d(2.0~4.0d),术后拔除腹腔引流管时间为(4.4±1.3)d,术后患者肝功能恢复至接近正常水平时间为(6.8±1.6)d,无肝衰竭发生。62例患者中,6例发生术后并发症,包括胸腹腔积液5例,腹腔感染3例,肺部感染2例,胆瘘2例,腹腔内出血1例,尿潴留1例,术后切口感染1例,同一患者可合并多种并发症;Clavien-Dindo分级Ⅲ级并发症2例,予对症治疗后均好转;其余患者均未出现明显并发症。62例患者术后住院时间为(13±9)d。术后13例患者行TACE预防性治疗,9例患者行4~6个疗程的辅助化疗,2例患者同时行TACE和辅助化疗,化疗药物为口服替吉奥或吉西他滨联合顺铂。(2)病理学检查结果:62例患者肿瘤直径为(5.4±3.3)cm,其中直径≤5cm38例,>5cm24例;大体形态肿块型56例,管内生长型4例,管周浸润型2例;术后病理学检查均提示胆管细胞癌,其中高分化腺癌10例,中分化腺癌37例,低分化腺癌15例。57例患者切缘距肿瘤边界>1.0cm,术后病理检查证实手术切缘阴性60例,管内生长型及管周浸润型患者中各1例手术切缘阳性;淋巴结阳性率为11/18,微血管侵犯16例,周围神经浸润4例;62例患者肿瘤TNM分期:ⅠA期14例,ⅠB期23例,Ⅱ期14例,ⅢB期11例。(3)随访及生存情况:62例患者均获得随访,随访时间为(22±12)个月,1、3年无瘤生存率分别为65.2%和39.8%,1、3年总体生存率分别为89.6%和52.5%。44例未行淋巴结清扫患者中术后2例出现肝门部淋巴结转移,1例出现腹腔淋巴结广泛转移,2例分别于术后6个月及18个月因其他原因死亡。结论肝内胆管癌行腹腔镜肝切除术中区域淋巴结清扫安全有效,但管内生长型及管周浸润型患者应慎重选择腹腔镜肝切除术。

Objective To investigate the clinical efficacy of laparoscopic hepatectomy for intrahepatic cholangiocarcinoma(ICC).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 62 patients with ICC who were admitted to Mengchao Hepatobiliary Hospital of Fujian Medical University(32 patients)and the First Hospital Affiliated to Army Medical University(30 patients)between January 2013 and January 2018 were collected;there were 35 males and 27 females,aged from 25 to 77 years,with an average of 60 years.According to the preoperative and intraoperative situations,lymph node dissection was performed,and anatomical or non-anatomical laparoscopic hepatectomy were performed based on tumor size and location.Observation indicators:(1)surgical and postoperative recovery;(2)pathological examination results;(3)follow-up and survival situations.Follow-up was conducted by telephone interview and outpatient examination once every 3 months to detect tumor-free survival and overall survival of patients up to June 2018.Measurement data with normal distribution were represented as Mean±SD.Measurement data with skewed distribution were represented as M(range).Count data were described as absolute number and percentage.The survival curve and rate were drawn and calculated by the Kaplan-Meier method.Results(1)Surgical and postoperative recovery:all the 62 patients received successful laparoscopic hepatectomy,without conversion to open surgery or preoperative death,including 40 with anatomical hepatectomy and 22 with non-anatomical hepatectomy.There were 18 patients undergoing regional lymph node dissection.The operation time of 62 patients was(217±86)minutes.Of 62 patients,12 had hepatic vascular occlusion using the Pringle method with a total occlusion time of(14±7)minutes,45 received selective hepatic vascular occlusion and 5 did not receive hepatic portal occlusion.The volume of intraoperative blood loss was 282 mL(range,20-2 500 mL).Four patients had intraoperative infusion of suspended red blood cells.The time for out-of-bed activity,time to initial anal exsufflation,time of abdominal drainage-tube removal,recovery time of liver function to normal level were 1 day(range,1-3 days),2.5 days(2.0-4.0 days),(4.4±1.3)days,(6.8±1.6)days.There was no liver failure.Six of 62 patients had postoperative complications,including 5 with thoracic and abdominal effusion,3 with abdominal infection,2 with pulmonary infection,2 with bile leakage,1 with intraperitoneal hemorrhage,1 with urinary retention,1 with postoperative incision infection,multiple complications might occur in the same patient.Two of 6 patients with complications of Clavien-DindoⅢwere improved by symptomatic treatment.The other patients had no clear complications.The duration of postoperative hospital stay was(13±9)days.Thirteen patients received preventive TACE treatment after surgery,9 received 4-6 courses of chemotherapy,2 received both TACE and chemotherapy with chemotherapy drug of Tegafur or gemcitabine combined with cisplatin.(2)Pathological examination results:the tumor diameter of 62 patients was(5.4±3.3)cm,including 38 with the diameter≤5 cm and 24 with the diameter>5 cm.There were 56 patients of mass-forming type,4 of intraductal growth type and 2 of periductal infiltrating type.High-,moderate-,poor-differentiated adenocarcinoma were respectively detected in 10,37 and 15 of 62 patients.The distance of surgical margins to tumor was>1.0 cm in 57 patients.There were 60 patients with negative surgical margin,1 patient of intraductal growth type and 1 of periductal infiltrating type with positive margin.Lymph node dissection was performed in 18 patients,among which 11 were pathologically positive,otherwise,there were 16 patients with microvascular invasion,and 4 patients with peripheral nerve infiltration.TNM stages of 62 patients:stageⅠA,stageⅠB,stageⅡand stageⅢB were respectively detected in 14,23,14 and11 patients.(3)Follow-up and survival situations:62 patients were followed up for(22±12)months.The 1-and 3-year disease-free survival rates were 65.2%and 39.8%respectively.The 1-and 3-year overall survival rates were 89.6%and 52.5%respectively.During the follow-up,2 of 44 patients without lymph node dissection had liver portal lymph node metastasis,1 had extensive lymph node metastasis,2 died of other causes at 6 months and 18 months after operation.Conclusion Routine laparoscopic radical resection of intrahepatic cholangiocarcinoma with regional lymph node dissection is safe and effective,however,laparoscopic hepatectomy should be carefully selected for intraductal growth type and periductal infiltration type.